An area of erythema on the child's skin is being assessed by the nurse. The nurse presses down on the area, and the area becomes white. What term does the nurse document for this finding?
Blanching
Warmth
Redness
Nonblanching
The Correct Answer is A
Choice A reason: Blanching is the term that the nurse documents for this finding, because it describes the temporary whitening of the skin when pressure is applied. Blanching indicates that the blood vessels in the skin are constricted or compressed, and that the blood flow is reduced or interrupted. Blanching can be a normal response to cold, stress, or pressure, or it can be a sign of a problem, such as ischemia, infection, or inflammation.
Choice B reason: Warmth is not the term that the nurse documents for this finding, because it describes the increased temperature of the skin, not the color change. Warmth indicates that the blood vessels in the skin are dilated or expanded, and that the blood flow is increased or enhanced. Warmth can be a normal response to heat, exercise, or emotion, or it can be a sign of a problem, such as infection, inflammation, or allergy.
Choice C reason: Redness is not the term that the nurse documents for this finding, because it describes the original color of the skin, not the color change. Redness indicates that the blood vessels in the skin are dilated or expanded, and that the blood flow is increased or enhanced, as explained above. Redness can be a normal response to heat, exercise, or emotion, or it can be a sign of a problem, such as infection, inflammation, or allergy.
Choice D reason: Nonblanching is not the term that the nurse documents for this finding, because it describes the opposite of what the nurse observed. Nonblanching means that the skin does not turn white when pressure is applied, but rather remains red or purple. Nonblanching indicates that the blood vessels in the skin are damaged or ruptured, and that the blood has leaked into the surrounding tissues. Nonblanching can be a sign of a serious problem, such as bruising, bleeding, or necrosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A reason: Include many fresh fruits and vegetables in your diet is not a correct answer, because it may increase the risk of infection for the client with AIDS. Fresh fruits and vegetables may contain bacteria, parasites, or pesticides that can cause gastrointestinal or systemic infections in immunocompromised clients. The nurse should advise the client to wash, peel, or cook fruits and vegetables before eating them, or to avoid them altogether if they have diarrhea or low white blood cell counts.
Choice B reason: Drink at least 2 to 3 L of fluids per day is a correct answer, because it helps prevent dehydration, maintain electrolyte balance, and flush out toxins and waste products. Fluid intake is especially important for clients with AIDS who may experience fever, sweating, vomiting, diarrhea, or oral lesions that can cause fluid loss.
Choice C reason: Eat highcalorie foods is a correct answer, because it helps prevent weight loss, muscle wasting, and malnutrition. Clients with AIDS may have increased caloric needs due to increased metabolic rate, infection, inflammation, or medication side effects. Highcalorie foods can provide energy and support immune function.
Choice D reason: Lower your caloric intake is not a correct answer, because it can worsen the nutritional status and health outcomes of the client with AIDS. Lowering caloric intake can lead to weight loss, muscle wasting, malnutrition, and increased susceptibility to infections and complications. The nurse should encourage the client to meet or exceed their caloric needs based on their weight, activity level, and disease stage.
Choice E reason: Choose foods high in protein is a correct answer, because it helps maintain muscle mass, tissue repair, and immune function. Clients with AIDS may have increased protein needs due to increased protein breakdown, infection, inflammation, or medication side effects. Highprotein foods can provide amino acids and antibodies that are essential for immune response.
Correct Answer is A
Explanation
Choice A reason: Fowler's position is a semisitting position with the head of the bed elevated at 45 to 60 degrees. This position allows for maximum expansion of the chest and improves ventilation and oxygenation. It also reduces the work of breathing and prevents the abdominal organs from compressing the diaphragm.
Choice B reason: Sim's position is a sidelying position with the lower arm behind the back and the upper knee flexed. This position is used for patients who are unconscious, have difficulty swallowing, or are receiving an enema. It does not facilitate breathing or oxygenation for patients with COPD.
Choice C reason: Prone position is a lying position with the face down and the arms at the sides or bent at the elbows. This position is used for patients with acute respiratory distress syndrome (ARDS) or severe lung injury to improve oxygenation and reduce lung inflammation. It is not recommended for patients with COPD as it may increase the risk of aspiration, pressure ulcers, and nerve damage.
Choice D reason: Lateral position is a sidelying position with the upper leg slightly flexed and supported by a pillow. This position is used for patients who are resting or sleeping to prevent pressure ulcers and promote comfort. It does not improve breathing or oxygenation for patients with COPD.
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